Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW- <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT [9 COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name Alpha Fast Gas Phone# <br /> I Address 2358 E Waterloo Rd Stockton 95205 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Jimmy Phone# <br /> C, Contractor Name Service Station Testing-SST INC Phone# (209)465-5577 <br /> o Contractor Address PO Box 31465-Stockton, CA 95213 CA Lic# 962520 Class q 1B 1 C-10,20,38 <br /> T <br /> A Insurer EXEMPT Work Comp# NIA <br /> T ICC Technician's Name Carl Wayne Henderson (5252923) Expiration Date 08110/2014 <br /> QICC installer's Name NIA Expiration Date NIA <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> [..a.87 piping sump,91 leak detector,t1DC 1l2..etc.) Instalied <br /> T <br /> A <br /> N <br /> K <br /> P ❑I Approved pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A 2D !3 <br /> N Plan Reviewers Name <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature `� � Title Authorized Agent Date 1124113 <br /> BILLING INFORMATION <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Carl Wayne Henderson TITLE President PHONE# (209)467-7573 <br /> ADDRESS PO Box 31325- Stockton, CA 95213 <br /> SIGNATURE u DATE 1124113 <br /> EH230038(revised 02120109) <br /> 1 <br />